The Efficient Funding of Chemotherapy (EFC) measure was introduced to calculate PBS reimbursement on the basis of the cheapest possible combination of vials, minimising the cost of each infusion to taxpayers and thus contributing to the sustainability of the chemotherapy program.
A reimbursement algorithm calculates the appropriate PBS reimbursement, including the retail mark-up and applicable preparation and dispensing fees, as follows:
1.
The ex-manufacturer price for a single vial is derived.
2.
The retail mark-up on a single vial is calculated.
Retail mark-ups for infusions dispensed by a community pharmacy are set out in the
Fifth Community Pharmacy Agreement (5CPA) for community pharmacy (table 1). s94 private hospitals receive a flat 1.4% mark-up on the medicine cost and s94 public hospitals do not receive a mark-up on the medicine cost.
Drug cost (ex-manufacturer)
Less than or equal to $30.00
$30.00-$45.00
$45.01-$180.00
$180.01-$450.00
$450.01-$1750.00
Over $1750.00
Table 1. Retail mark-up tiers (s90 community pharmacy as per 5CPA)
Retail mark-up on medicine cost
15.00%
$4.50
10.00%
$18.00
4.00%
$70.00
3.
The per-vial medicine price is derived.
4.
The total medicine price for the infusion/patient dose is calculated, based on the cheapest combination of vials.
5.
The applicable dispensing and dispensing fees are added to give the dispensed price.
Wholesale/distribution fee
Diluent fee
Preparation fee
Dispensing Fee
Total fee
Community Pharmacy
$24.79
$4.91
$41.33
$6.63
$77.66
Public Hospital
$41.33
$41.33
The pharmacy is reimbursed the dispensed price, minus any patient co-payments.
Private Hospital
$24.79
$4.91
$41.33
$6.63
$77.66
Example of a dispensed price calculation for an infusion supplied in an approved community pharmacy.
Step One: Derive price ex-manufacturer for a single vial
Vial
Powder for I.V. infusion 100 mg
Powder for I.V. infusion 500 mg
Ex man price
$311.97
$1559.86

Step Two: Calculate mark-up on single vial
Vial
100 mg
500 mg
Vials required for maximum amount
11
3
Ex man price for maximum amount
$311.97 × 11 =
$3431.67
$1559.86 × 3 =
$4679.58
Step Three : Derive per-vial medicine price
Vial
100 mg
500 mg
Vial price including mark-up
$311.97 + $6.36 = $318.33 (3.1833 per mg)
$1559.86 + $23.33 = $1583.19 (3.16638 per mg)
Determine retail mark-up
$70
($1750+ band)
$70
($1750+ band)
Step Four : Calculate the total medicine price for the infusion/patient dose
The cheapest combination of vials to make up the max amount of 1100 mg is:
2 × 500 mg + 1 × 100 mg = $1583.19 × 2 + $318.33 = $3484.71
2 × 500 mg + 1 × 100 mg = $23.33 × 2 + $6.36 = $53.02
Step Five : Calculate the infusion’s dispensed price
The applicable fees for community pharmacy are:
Fee
Wholesale Fee
Diluent Fee
Preparation Fee
Ready Prepared Dispensing Fee
Total
Amount
$24.38
$4.83
$40.64
$6.52
$76.37
DPMA = $3484.71 + $76.37 = $3561.08
Mark-up per vial
$70 / 11 =
$6.36
$70/ 3 =
$23.33